Aim: Fetal maturity was estimated by various methods in 164 monochorionic diamniotic (MD) twins. Methods: Twin-to-tin transfusion syndrome (TTTS) was prevented by intensive maternal rest and tocolysis until Fetal adrenal cortex maturity, which was estimated in the initiation mechanism of uterine contraction, gray level histogram width (GLHW) of fetal lung and liver ratio multiplied by gestational weeks was used to estimate fetal lung maturity. Results and discussion: Fetal adreno-cortical steroid, reacted stresses after maturation, which caused Braxton- Hicks uterine contraction after 30 gestational weeks, where ultrasonic cardio-thprax ratio enlarged to 0.4 or more, then the MD twins received Caesarean delivery to prevent TTTS in 32 ± 2.2 gestational weeks where coefficient of variation (CV) of weeks was as small as 7%. Thus, fetal maturity was estimated to be 32 gestational weeks. As GLHW ratio of fetal lung and liver multiplied by gestational weeks was >29 in mature fetal lung, the index was 31 in 32 gestational weeks, and no problem was found in the iMD twins born in 32 ± 2.2 gestational weeks. Conclusion: Human fetus is mature in 32 gestational weeks.

Purpose: Objective ultrasonic B-mode image analysis in clinical ultrasound tissue characterization with echogenicity histogram in commercial B-mode devices. Materials: Placental intervillous space fibrin deposit, fetal growth restriction, malignant neoplasia, fetal brain echo density, fetal lung immaturity, meconium-stained amniotic fluid and adult liver. Methods: Commercial ultrasound B-mode histogram base width of a phantom divided by the full gray scale length was constant controlling B-mode gain; it was called gray level histogram width (GLHW) and used to tissue characterization. Image contrast should be lowest. Results: Fibrin deposit in placental intervillous space was diagnosed and treated with heparin to obtain normal neonate. Ovarian, cervical and endometrial malignancies were higher than 50% in GLHW. Fetal brain echo density and fetal lung immaturity were diagnosed. Meconium stained amniotic fluid GLHW was high. Adult liver GLHW will be studied in the future. Helsinki declaration was followed in the studies. Conclusion: The GLHW objectively diagnosed ultrasound B-mode image; thus, it should be widely used even in adult using commercial B-mode device.

Purpose: To establish the technique to predict hypoxia in its latent state, to estimate the severity of disorder, and to discuss the feasibility of fibrinolytic therapy.

Ultrasonic CTAR and PLI Indices Predict Neonatal Congestive Heart Failure in Monochorionic Twin Pregnancies

Seventeen cases (85%) of 20 non-reactive FHR cases of 1UGR diagnosed objectively by actocardiograrn developed severe NRFS within 15 days, and all of 20 cases (100%) had C-section, whereas 20 reactive FHR cases of 1UGR had 4 NRFS (4/20, 20%) and 6 C-section (6/20, 30%). There was significant difference between non-reactive and reactive FHR. The NRFS appeared more frequently during pregnancy in non-reactive FHR (15/17, 88.2%) than in pregnancy of reactive FHR (1/4, 25%). Neonatal condition was disturbed by low Apgar score or deaths in non-reactive FHR, while reactive FHR cases had uneventful courses. The actocardiogram was reliable in the lUGR management, particularly during pregnancy. The actocardiograrn was also used in the severity assessment of common fetal disorders by the FHR acceleration duration ratio to fetal movement burst.

Wide use of fetal surveillance in general delivery to improve perinatal outcome is the aim of our studies on computerized monitoring. The results of studies show higher cost-effectiveness in the conventional computer and artificial neural network systems than simple visual CTG diagnosis particularly in multiple simultaneous deliveries. The reason is high performance of the automated analysis, abnormality alarming function, the outcome probability report, and economical monitor systems without using chart recorder, low expense of computer, and the reduction of personnel expense.

Objective: The purpose of this prospective study is to verify whether fetal periventricular echodensity (PVE) precedes neonatal periventricular leukomalacia (PVL). Methods: Fetal brains were studied with transvaginal scan in 63 high-risk fetuses from 17 to 32 weeks of pregnancy, PVE echogenicity was quantified with ultrasonic histogram, and neonatal brains and clinical courses were studied after birth. Results: No fetal cystic PVL was found, instead, fetal PVE was detected in 42 fetuses. The quantified echogenicity value was higher in PVE than in normal brain. Four cases developed neonatal PVL among 28 preterm and 1 among 14 term births. Neonatal PVL developed in the 23 cases of persistent fetal PVE, whereas no neonatal PVL was found when fetal PVE was negative or disappeared. Cord compression signs were common in PVL cases. Conclusion: Neonatal PVL was preceded by antepartum persistent fetal PVE in the present study.

BackgroundThe aim is to clarify placental shunt flow patterns in monochorionic diamniotic (MD) twins and their clinical outcome after the intervention under unique criteria.MethodThirteen (13) MD twin pregnancies were studied from early pregnancy with 2D and 3D B‐mode, color Doppler, power‐angio mode, Doppler flow velocimetry, cardio‐thoraxarea ratio (CTAR) and preload index (PLI) under tocolysis.ResultsArtery to artery shunt flow was detected by fetalbeat‐to‐beat Doppler color change and cyclic bidirectionalflow at placental surface in 8 MD twin cases but not in 5. Shunt was more clear with 3D color Doppler and power‐angio. Umbilical vein flow pulsation, variable FHR deceleration andcord complications were more in placental shunt flow casesthan its absence. Deep shunt flow was prenatally detected in 2 cases and small anastomses in all postnatal placenta. Pregnancy was terminated by emergency C‐section in cases of uncontrollable contractions, unidirectional shunt flow, large CTAR and PLI (> 0.4) which were frequent in large twins after 30 weeks. Neonatal cardiac failure was more in shunt flow cases than its absence but the outcome was normal. Neonatal PVL and perinatal deaths were less than the MD twins in the past.

Grey-level histogram width (GLHW) values of fetal lung and liver were studied in 52 healthy fetuses in 24 to 38 weeks of pregnancy, comparing them to the mean grey level (MGL), grey-level standard deviation (GLSD) and the coefficient of variation (GLCV). Fetal lung GLHW was larger in 30–38 weeks than at 24–29 weeks, but there was no change in liver GLHW. GLHW was smaller in fetal lung than in the liver in 24–29 weeks, with no difference in 30–38 weeks. The lung/liver GLHW ratios were less than 1 in 24–29 weeks, but they were 1 or more in 30–35 weeks. Both MGL of fetal lung and liver showed linear increases during pregnancy, but no difference was found between the two. Fetal lung GLSD tended to decrease during pregnancy. The GLCV values of fetal lung and liver decreased during pregnancy, and differed between 24–29 weeks and 30–38 weeks, whereas there was no difference between fetal lung and liver. The correlation coefficients of GLHW and MGL of fetal lung and liver to the weeks of pregnancy were moderate, and the coefficients of GLSD and GLCV to the weeks of pregnancy were small. In conclusion, quantitatively measured echogenicity of fetal lung increased in 30 or more weeks of pregnancy, and suggested antepartum changes of fetal lung tissue. The GLHW is reliable, because it was reproducible in various gain settings of various ultrasonic imaging devices. The MGL, GLSD and GLCV are less reliable, because the grey level varied by the gain changes among various machines.

Neural network computer was useful for objective assessment of the outcome, Probability percentage made the decision easier than other system, but no FHR findings were shown by the neural network system, Detailed FHR findings were obtained by the experts knowledge system, Both computers are combined in the parallel-hybrid system in the future, which further promotes accurate and easy FHR diagnosis, The new system is also promising for various research works.

Objectives: Dynamic blood now changes of placental shunt vessels, which may cause twin-twin transfusion syndrome (TTTS) in monochorionic diamniotic (MD) twins, were studied. Materials and Methods: Seven MD twin pregnancies were studied. Anastomosed arterial blood now and its direction were visualized by color Doppler now mapping at placental surface on the chorionic plate. Shunt now patterns were analyzed with pulsed Doppler in steady state, during uterine contraction and fetal movement. Flow patterns of umbilical vessels, inferior vena cava (IV C), and fetal heart size were studied. Results: Arterial anastomoses were found in 4 MD twin pregnancies. Their flow directions changed frequently and cyclically. Bidirectional arterial flow patterns showed the heart beats of both twins in steady state without uterine contraction nor fetal movement, and cyclic changes developed due to the diffference of fetal heart rate. Umbilical arteries showed no abnormal now pattern. In uterine contraction or fetal movement, the now pattern of anastomosed shunt arteries was unidirectional, umbilical arterial or IVC now of the recipient was irregular, cardio-thorax-area ratio (CTAR) and preload Three MD eases of no shunt now showed no change of the parameters, and pregnancy was uneventful except a case who showed enlarged CTAR and had C-section, though the twins were somewhat discordant. Posterior placenta and cord twisting were more, and delivery weeks was less due to emergency C-section caused by acute TTTS in the shunt now cases. Velametous insertion and neonatal catecholamine therapy for cardiac failure tended to be more in shunt now. Conclusion: Detection and analysis of the blood flow of placental shunt vessels may be useful in the management of MD twins Changing into unidirectional shunt now may be real-time parameter of TTTS evaluation. Suppression of uterine contraction may be effective for the prevention of abnormal placental shunt flow and acute TTTS.

With advances in instrumentation, evaluation of fetal heart rate tracings can be combined with B-mode imaging to assess fetal activity and Doppler evaluation of cardiac activity. These additional approaches will allow investigation into the fetal active and resting states, as well as the fetal responses to acoustic and visual stimuli. Fetal motion analysis also demonstrates the scarce activity early in fetal life; fetal activity increases and movements become quicker at later gestation. Evaluation of fetal movements in addition to routine biophysical monitoring of fetal heart rate appears to be an attractive tool in the surveillance of fetal well-being.

> Objective: A nonsubjective evaluation of intrapartum fetal heart rate (FHR) with a neural network (NNW) computer system and its clinical application. Methods: Eight simple FHR data were input into the NNW computer after 16-step normalizations. The computer was composed of 40 units in the input layer, 30 in intermediate layer, and 3 in the output layer, and the probabilities to be normal, suspicious, and pathological were obtained at the output. Before use, the computer was trained 10,000 times by 50-min teacher FHR data of 20 cases with known outcomes. The trained NNW computer was tested by FHRs of another 29 cases. The outcome probabilities in 15 min were calculated every 5 min in another 10 cases, and the bar graphs of the probabilities were displayed in sequence in the trendgrams. Results: The trained NNW computer was 100% accurate in the internal check; in the external check 86% of the results were evaluated correctly with the cardiotocogram, Apgar score, and umbilical arterial pH of the 29 test cases. The FHR scores of our conventional computer FHR analysis were higher in the suspicious and pathological groups than the normal group, and the fetal distress index was high in the pathological group. The trendgrams were simply accurate in typically normal or abnormal cases, transitory abnormal probabilities were shown in intermediate cases, and mixed suspicious and pathological probabilities suggested pathological outcome. Conclusions: The outcome probabilities and their trendgrams in the NNW FHR analysis are promising in objective decision making in the intrapartum stage.

Grey-level histogram width (GLHW) values obtained by common sonographic devices were large in echogenic image and small in less echoic parts. The Aloka UIP-100 computer system, SSD-680, and Toshiba SSA-270A sonographs showed GLHW values not significantly different when tested with RMI-412 phantom with the device contrast set at the lowest level. No influence on the GLHW value was observed by the changes of device gain, STC or image depth in the range of clinical practice. Device contrast control influenced the value. Although two sonographs showed significant differences from UIP-100, they were easily corrected by a small factor. Normal ranges of GLHW values of the placenta were obtained every 2 weeks, from 20 to 41 weeks, in 222 normal pregnancies measured by old scanners. GLHW values of normal pregnancies measured by the new Aloka and Toshiba machines were distributed within the normal ranges, and those of Grannum Grade III abnormally echogenic placenta were greater than the upper normal range. GLHW is a reproducible value among commercial ultrasonic devices, and the value is useful in clinical practice. Manual and automated GLHW values were identical.